Asbestos Abatement Supervisor Application

3017 N. STILES, OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 07/13/2012 Toll Free Number (888) 269-5353 Page 1 of 4 Oklahoma Department of Labor
Mark Costello
COMMISSIONER OF LABOR
ASBESTOS ABATEMENT
SUPERVISOR APPLICATION
NEW RENEWAL LICENSE #
1. Applicant’s Name
2. Home Address
3. City
4. State
5. Zip
6. Date of Birth
7. Social Security Number
8. Phone
8. Hair Color
9. Eye Color
10. Weight
11. Height
12. Company Name
13. Company Address
14. City
15. State
16. Zip
17. Company Phone
18. Company Contact Person
ALL APPLICANTS MUST SUBMIT THE FOLLOWING:
1. A copy of your current drivers license or state issued photo identification card.
2. Copy(s) of current refresher training class*
3. Copy(s) of Cardiopulmonary Resuscitation (CPR) training class
4. Copy(s) of First Aid class
5. Provide social security card, birth certificate, valid unexpired passport or W-2 form.
NEW APPLICANTS MUST ALSO SUBMIT THE FOLLOWING, IN PERSON:
1. Copies of Original Contractor/Supervisor training class and all subsequent refresher courses*
2. Copies of Confined Space Entry*
3. Copies of NIOSH 582 or Air Monitoring*
4. Affidavit regarding citizenship.
5. Provide social security card, birth certificate, valid unexpired passport or W-2 form.
*Training must have been provided by an educational institution, government agency or labor union and must have been accredited by the U.S. Environmental Protection Agency. FOR OFFICE USE ONLY
Date
DEO
Receipt No.
License No.
Asbestos Admin Approval/Date Type of Payment
1 2 3
#
Endorser 3017 N. STILES, OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 07/13/2012 Toll Free Number (888) 269-5353 Page 2 of 4 Do you currently hold any other Oklahoma Asbestos Licenses? YES NO
If yes, please indicate the type of license and the license number: CHECK TYPE LICENSE LICENSE NUMBER
CHECK TYPE LICENSE LICENSE NUMBER
Worker
Inspector
Mgmt. Planner
Project Designer
Please check one of the following:
NON-EXEMPT
Submit check or money order for $25.00 made payable to the Oklahoma Department of Labor
OR
EXEMPT
If the applicant is the employee of a political subdivision of the State of Oklahoma and agrees to perform any AHERA asbestos work on behalf of that employer only, no fee is required
Do you have any asbestos violations? YES NO
If yes, please list job and type of violation:
Abatement Projects
ONLY NEW APPLICANTS MUST COMPLETE THIS SECTION
List six (6) abatement projects on which you worked:
1. Employer:_______________________________
Phone:__________________________________
Project name: ____________________________
Dates from/to: ___________________________
Contact Person: __________________________
2. Employer:_______________________________
Phone:__________________________________
Project name: ____________________________
Dates from/to: ___________________________
Contact Person: __________________________
3. Employer:_______________________________
Phone:__________________________________
Project name: ____________________________
Dates from/to: ___________________________
Contact Person: __________________________
4. Employer:_______________________________
Phone:__________________________________
Project name: ____________________________
Dates from/to: ___________________________
Contact Person: __________________________
5. Employer:_______________________________
Phone:__________________________________
Project name: ____________________________
Dates from/to: ___________________________
Contact Person: __________________________
6. Employer:_______________________________
Phone:__________________________________
Project name: ____________________________
Dates from/to: ___________________________
Contact Person: __________________________
3017 N. STILES, OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 07/13/2012 Toll Free Number (888) 269-5353 Page 3 of 4 Employment History
ONLY NEW APPLICANTS MUST COMPLETE THIS SECTION
If you have more than three separate previous employments, please sign and attach additional sheets in the same format as below: Employers Name:
Employers Address:
Dates from/to:
Contact Person: Employers Name:
Employers Address:
Dates from/to:
Contact Person: Employers Name:
Employers Address:
Dates from/to:
Contact Person:
I hereby authorize the educational institutions to release verification of completion of the courses presented in this application.
I further affirm, upon my oath, to follow Title 40 of the Oklahoma Statutes, Section 450 through 456 as amended, and the Abatement of Friable Asbestos Materials Rules OAC 380, Chapter 50. I understand that a violation of any law or rule may subject my license to be suspended or revoked, or may subject me to cease and desist orders, injunctive measures, and criminal penalties for criminal violations.
I, upon my oath, do state that the above information is a true statement, and further state that I am not under any type of disciplinary action, including license revocation or suspension, by any State or political division thereof, or by the United States government, for any illegal or improper activity, civil or criminal, involving asbestos-containing material.
Applicants Signature Date
3017 N. STILES, OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 07/13/2012 Toll Free Number (888) 269-5353 Page 4 of 4 OAC 380:50-5-8. Licensing of Asbestos Abatement Supervisors: Licensing requirements for Asbestos Abatement Supervisors are as follows: (1) Applications shall be submitted on forms prescribed by the Commissioner. (2) The license fee shall be twenty-five dollars ($25.00) per year. (3) The license shall be issued for a period not to exceed one year and shall expire concurrently with the asbestos training and subsequent refresher training. There will be no grace period wherein a Supervisor will be allowed to work with an expired license. (4) Asbestos Abatement Supervisors shall have successfully completed and shall provide documentation for: (A) an Asbestos Abatement Supervisor’s course and all subsequent Supervisor refresher training which fully meets the requirements of OAC 380:50-6-3 and 380:50-6-8. (B) a two day, or equivalent course in confined space entry following the NIOSH curriculum in confined space entry. (C) the NIOSH 582 course in Analysis of Airborne Asbestos Dust, or equivalent, or a minimum of a two day course in air monitoring techniques. (D) current cardiopulmonary resuscitation (CPR) training, which may be provided by the National Heart Association, The American Red Cross, or other approved training provider. (E) current first aid training, which may be provided by The American Red Cross, or other approved training provider. (F) Six months experience as an Asbestos Abatement Worker on job sites that have been inspected by DOL, including a minimum of six different abatement projects or containments, or one year experience as an Asbestos Abatement Worker and six months as an Asbestos Abatement Supervisor on projects which have not been inspected by DOL. (5) Licenses shall be issued in the name of the individual applicant and shall be valid only when working for a licensed Contractor. (6) License cards shall be available at the job site for inspection by the Department of Labor.
OAC 380:50-6-3. Initial training for Asbestos Contractors and Supervisors: Training requirements are as follows: (1) Training shall be supplied by an EPA or DOL accredited educational institution, labor union, or government agency, or from a private vocational education provider licensed by the state where it operates (pursuant to 70 O.S. § 21-103 within the state of Oklahoma and accredited by EPA or an EPA approved governmental agency. (2) Training providers must have EPA approval or approval by a state that has an approved Model Accreditation Plan (MAP) that is as stringent or exceeds the minimum requirements of the EPA MAP. (3) Asbestos Abatement Supervisor training courses shall be no less than five days in length and shall include: lectures, demonstrations, at least 14 hours of hands-on training, individual respirator fit testing, course review and an examination. (4) Asbestos Abatement Supervisor training courses shall consist of the training required in OAC 380:50-6-3 and 380:50-6-8.

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3017 N. STILES, OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 07/13/2012 Toll Free Number (888) 269-5353 Page 1 of 4 Oklahoma Department of Labor
Mark Costello
COMMISSIONER OF LABOR
ASBESTOS ABATEMENT
SUPERVISOR APPLICATION
NEW RENEWAL LICENSE #
1. Applicant’s Name
2. Home Address
3. City
4. State
5. Zip
6. Date of Birth
7. Social Security Number
8. Phone
8. Hair Color
9. Eye Color
10. Weight
11. Height
12. Company Name
13. Company Address
14. City
15. State
16. Zip
17. Company Phone
18. Company Contact Person
ALL APPLICANTS MUST SUBMIT THE FOLLOWING:
1. A copy of your current drivers license or state issued photo identification card.
2. Copy(s) of current refresher training class*
3. Copy(s) of Cardiopulmonary Resuscitation (CPR) training class
4. Copy(s) of First Aid class
5. Provide social security card, birth certificate, valid unexpired passport or W-2 form.
NEW APPLICANTS MUST ALSO SUBMIT THE FOLLOWING, IN PERSON:
1. Copies of Original Contractor/Supervisor training class and all subsequent refresher courses*
2. Copies of Confined Space Entry*
3. Copies of NIOSH 582 or Air Monitoring*
4. Affidavit regarding citizenship.
5. Provide social security card, birth certificate, valid unexpired passport or W-2 form.
*Training must have been provided by an educational institution, government agency or labor union and must have been accredited by the U.S. Environmental Protection Agency. FOR OFFICE USE ONLY
Date
DEO
Receipt No.
License No.
Asbestos Admin Approval/Date Type of Payment
1 2 3
#
Endorser 3017 N. STILES, OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 07/13/2012 Toll Free Number (888) 269-5353 Page 2 of 4 Do you currently hold any other Oklahoma Asbestos Licenses? YES NO
If yes, please indicate the type of license and the license number: CHECK TYPE LICENSE LICENSE NUMBER
CHECK TYPE LICENSE LICENSE NUMBER
Worker
Inspector
Mgmt. Planner
Project Designer
Please check one of the following:
NON-EXEMPT
Submit check or money order for $25.00 made payable to the Oklahoma Department of Labor
OR
EXEMPT
If the applicant is the employee of a political subdivision of the State of Oklahoma and agrees to perform any AHERA asbestos work on behalf of that employer only, no fee is required
Do you have any asbestos violations? YES NO
If yes, please list job and type of violation:
Abatement Projects
ONLY NEW APPLICANTS MUST COMPLETE THIS SECTION
List six (6) abatement projects on which you worked:
1. Employer:_______________________________
Phone:__________________________________
Project name: ____________________________
Dates from/to: ___________________________
Contact Person: __________________________
2. Employer:_______________________________
Phone:__________________________________
Project name: ____________________________
Dates from/to: ___________________________
Contact Person: __________________________
3. Employer:_______________________________
Phone:__________________________________
Project name: ____________________________
Dates from/to: ___________________________
Contact Person: __________________________
4. Employer:_______________________________
Phone:__________________________________
Project name: ____________________________
Dates from/to: ___________________________
Contact Person: __________________________
5. Employer:_______________________________
Phone:__________________________________
Project name: ____________________________
Dates from/to: ___________________________
Contact Person: __________________________
6. Employer:_______________________________
Phone:__________________________________
Project name: ____________________________
Dates from/to: ___________________________
Contact Person: __________________________
3017 N. STILES, OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 07/13/2012 Toll Free Number (888) 269-5353 Page 3 of 4 Employment History
ONLY NEW APPLICANTS MUST COMPLETE THIS SECTION
If you have more than three separate previous employments, please sign and attach additional sheets in the same format as below: Employers Name:
Employers Address:
Dates from/to:
Contact Person: Employers Name:
Employers Address:
Dates from/to:
Contact Person: Employers Name:
Employers Address:
Dates from/to:
Contact Person:
I hereby authorize the educational institutions to release verification of completion of the courses presented in this application.
I further affirm, upon my oath, to follow Title 40 of the Oklahoma Statutes, Section 450 through 456 as amended, and the Abatement of Friable Asbestos Materials Rules OAC 380, Chapter 50. I understand that a violation of any law or rule may subject my license to be suspended or revoked, or may subject me to cease and desist orders, injunctive measures, and criminal penalties for criminal violations.
I, upon my oath, do state that the above information is a true statement, and further state that I am not under any type of disciplinary action, including license revocation or suspension, by any State or political division thereof, or by the United States government, for any illegal or improper activity, civil or criminal, involving asbestos-containing material.
Applicants Signature Date
3017 N. STILES, OKLAHOMA CITY, OKLAHOMA 73105 ∙ www.labor.ok.gov ∙ PHONE: (405)521-6464 ∙ FAX (405) 521-6016
Revised 07/13/2012 Toll Free Number (888) 269-5353 Page 4 of 4 OAC 380:50-5-8. Licensing of Asbestos Abatement Supervisors: Licensing requirements for Asbestos Abatement Supervisors are as follows: (1) Applications shall be submitted on forms prescribed by the Commissioner. (2) The license fee shall be twenty-five dollars ($25.00) per year. (3) The license shall be issued for a period not to exceed one year and shall expire concurrently with the asbestos training and subsequent refresher training. There will be no grace period wherein a Supervisor will be allowed to work with an expired license. (4) Asbestos Abatement Supervisors shall have successfully completed and shall provide documentation for: (A) an Asbestos Abatement Supervisor’s course and all subsequent Supervisor refresher training which fully meets the requirements of OAC 380:50-6-3 and 380:50-6-8. (B) a two day, or equivalent course in confined space entry following the NIOSH curriculum in confined space entry. (C) the NIOSH 582 course in Analysis of Airborne Asbestos Dust, or equivalent, or a minimum of a two day course in air monitoring techniques. (D) current cardiopulmonary resuscitation (CPR) training, which may be provided by the National Heart Association, The American Red Cross, or other approved training provider. (E) current first aid training, which may be provided by The American Red Cross, or other approved training provider. (F) Six months experience as an Asbestos Abatement Worker on job sites that have been inspected by DOL, including a minimum of six different abatement projects or containments, or one year experience as an Asbestos Abatement Worker and six months as an Asbestos Abatement Supervisor on projects which have not been inspected by DOL. (5) Licenses shall be issued in the name of the individual applicant and shall be valid only when working for a licensed Contractor. (6) License cards shall be available at the job site for inspection by the Department of Labor.
OAC 380:50-6-3. Initial training for Asbestos Contractors and Supervisors: Training requirements are as follows: (1) Training shall be supplied by an EPA or DOL accredited educational institution, labor union, or government agency, or from a private vocational education provider licensed by the state where it operates (pursuant to 70 O.S. § 21-103 within the state of Oklahoma and accredited by EPA or an EPA approved governmental agency. (2) Training providers must have EPA approval or approval by a state that has an approved Model Accreditation Plan (MAP) that is as stringent or exceeds the minimum requirements of the EPA MAP. (3) Asbestos Abatement Supervisor training courses shall be no less than five days in length and shall include: lectures, demonstrations, at least 14 hours of hands-on training, individual respirator fit testing, course review and an examination. (4) Asbestos Abatement Supervisor training courses shall consist of the training required in OAC 380:50-6-3 and 380:50-6-8.